Dual Antiplatelet Therapy in Ischemic Stroke Prevention: Which Two Could Be Better than One?

Recurrent stroke after ischemic stroke (IS) or high-risk transient ischemic attack (TIA) increases morbidity and mortality. Secondary stroke prevention strategies include modification of behavioral and vascular risk factors and antithrombotic use, including single or dual antiplatelet therapy (DAPT). In this review, we focus on DAPT indications, combinations, and treatment duration. Studies showed that for patients with mild to moderate non-cardioembolic strokes or those with symptomatic intracranial or mild extracranial stenosis (≤ 30% diameter reduction), short-term DAPT (21–90 days) with aspirin plus clopidogrel, compared with mono-antiplatelet therapy (MAPT), decreases recurrent stroke risk without significantly increasing major bleeding risk. The combination of aspirin plus extended release dipyridamole or cilostazol may confer decrease of risk for recurrent stroke with long-term use, at the expense of increasing major bleeding risk. Treatment with aspirin plus ticagrelor for a short time period is superior to aspirin monotherapy for decreasing risk for recurrent stroke, but significantly increases the risk for major bleeding. Short-term DAPT with aspirin plus clopidogrel, compared with MAPT, decreases risk for recurrent stroke without increasing major bleeding risk. Short-term DAPT with aspirin plus ticagrelor also reduces risk for recurrent stroke, but with a significant increase in the risk of major bleeding, compared with MAPT. Direct comparisons among different DAPT regimens are currently underway.